You are on page 1of 5

SCHEDULE B Actuarial Information OMB No.

1210-0016
(Form 5500) This schedule is required to be filed under section 104 of the Employee
Retirement Income Security Act of 1974, referred to as ERISA, except when
Department of the Treasury attached to Form 5500-EZ and, in all cases, under section 6059(a) of the
Internal Revenue Service Internal Revenue Code, referred to as the Code. This Form Is Open to
Department of Labor Public Inspection
Pension and Welfare Benefits Administration © Attach to Form 5500, 5500-C/R, or 5500-EZ if applicable. (except when attached
Pension Benefit Guaranty Corporation © See separate instructions. to Form 5500-EZ)
For calendar plan year 1995 or fiscal plan year beginning , 1995, and ending , 19
© If an item does not apply, enter “N/A.” © Round off amounts to nearest dollar.
© Caution: A penalty of $1,000 will be assessed for late filing of this report unless reasonable cause is established.
A Name of employer/plan sponsor as shown on line 1a of Form 5500, 5500-C/R, or 5500-EZ B Employer identification number

C Name of plan D Three-digit


plan number ©
E Type of plan: (1) Single employer (2) Multiemployer (3) Multiple employer F 100 or fewer participants in prior plan year
Part I Basic Information (To be completed by all plans)
1a Enter the actuarial valuation date: Month Day Year
b Assets:
(1) Current value of assets b(1)
(2) Actuarial value of assets for funding standard account b(2)
c (1) Accrued liability for plans using immediate gain methods c(1)
(2) Information for plans using spread gain methods:
(a) Unfunded liability for methods with bases c(2)(a)
(b) Accrued liability under entry age normal method c(2)(b)
(c) Normal cost under entry age normal method c(2)(c)
d Information on current liabilities of the plan:
(1) Amount excluded from current liability attributable to pre-participation service (see
instructions) d(1)
(2) “RPA ’94” information:
(a) Current liability d(2)(a)
(b) Expected increase in current liability due to benefits accruing during the plan year d(2)(b)
(c) Current liability computed at highest allowable interest rate (see instructions) d(2)(c)
(3) “OBRA ’87” information:
(a) Current liability d(3)(a)
(b) Expected increase in current liability due to benefits accruing during the plan year d(3)(b)
(4) Expected plan benefit payments during the plan year d(4)
2 Operational information as of beginning of this plan year:
a Current value of the assets as reported on Form 5500, 5500-C/R, or 5500-EZ 2a
(1) No. of Persons (2) Vested Benefits (3) Total Benefits
b “RPA ’94” current liability:
(1) For retired participants and beneficiaries receiving payments
(2) For terminated vested participants
(3) For active participants
(4) Total
c If the percentage resulting from dividing line 2a by line 2b(4), column (3), is less than 70%, enter
such percentage 2c . %
Statement by Enrolled Actuary (see instructions before signing):
To the best of my knowledge, the information supplied in this schedule and on the accompanying statements, if any, is complete and accurate, and in my opinion
each assumption used in combination, represents my best estimate of anticipated experience under the plan. Furthermore, in the case of a plan other than a multiemployer
plan, each assumption used (a) is reasonable (taking into account the experience of the plan and reasonable expectations) or (b) would, in the aggregate, result in a
total contribution equivalent to that which would be determined if each such assumption were reasonable. In the case of a multiemployer plan, the assumptions used,
in the aggregate, are reasonable (taking into account the experience of the plan and reasonable expectations).

Signature of actuary Date


G —
Print or type name of actuary Most recent enrollment number

Firm name Telephone number (including area code)

Address of the firm

If the actuary has not fully reflected any regulation or ruling promulgated under the statute in completing this schedule,
check the box and see instructions
For Paperwork Reduction Act Notice, see the Instructions for Form 5500, 5500-C/R or 5500-EZ. Cat. No. 13507E Schedule B (Form 5500) 1995
Schedule B (Form 5500) 1995 Page 2
3 Contributions made to the plan for the plan year by employer(s) and employees:
(a) (b) (c) (a) (b) (c)
Month-Day-Year Amount paid by Amount paid by Month-Day-Year Amount paid by Amount paid by
employer employees employer employees

3 Totals © (b) (c)


4 Quarterly contributions and liquidity shortfall(s):
a Plans other than multiemployer plans, enter funded current liability percentage for preceding
year (see instructions) 4a . %
b If line 4a is less than 100%, plans with more than 100 participants see instructions, and complete
the following table as applicable:
Liquidity shortfall as of end of Quarter of this plan year
(1) 1st (2) 2nd (3) 3rd (4) 4th

5 Actuarial cost method used as the basis for this plan year’s funding standard account computation:
a Attained age normal b Entry age normal c Accrued benefit (unit credit)
d Aggregate e Frozen initial liability f Individual level premium
g Individual aggregate h Other (specify) ©
i Has a change been made in funding method for this plan year? Yes No
j If line i is “Yes,” was the change made pursuant to a Revenue Procedure with respect to which all
conditions for approval were satisfied? Yes No
k If line i is “Yes,” and line j is “No” enter the date of the ruling letter approving the
change in funding method Month Day Year
6 Checklist of certain actuarial assumptions: Pre-retirement Post-retirement

a Rates specified in insurance or annuity contracts 6a Yes No Yes No


b Mortality table code for valuation purposes:
(1) Males b(1)
(2) Females b(2)
c Interest rates for:
(1) “RPA ’94” current liability c(1) . % . %
(2) “OBRA ’87” current liability c(2) . % . %
(3) Valuation interest rate c(3) . % . %
d Expense loading 6d . % . %
e Weighted average retirement age 6e
Male Female
f Annual withdrawal rates:
(1) Age 25 f(1) . % . %
(2) Age 40 f(2) . % . %
(3) Age 55 f(3) . % . %
g Salary scale 6g . % . %
h Estimated investment return on actuarial value of assets for the year ending on the valuation date 6h . %

7 New amortization bases established in the current plan year:


(1) Type of Base (2) Initial Balance (3) Amortization Charge/Credit
Schedule B (Form 5500) 1995 Page 3
8 Miscellaneous information:
a If a waiver of a funding deficiency or an extension of an amortization period has been approved for this plan year, enter the
date of the ruling letter granting the approval Month Day Year
b If one or more alternative methods or rules (as listed in the instructions) were used for this plan year, enter the appropriate
code in accordance with the instructions ©
9 Funding standard account statement for this plan year:
Charges to funding standard account:
a Prior year funding deficiency, if any 9a
b Employer’s normal cost for plan year as of valuation date 9b
c Amortization charges as of valuation date: Outstanding Balance
(1) All bases except funding waivers © ($ ) c(1)
(2) Funding waivers © ($ ) c(2)
d Interest as applicable on lines 9a, 9b, and 9c 9d
e Additional interest charge due to late quarterly contributions, if applicable 9e
f Additional funding charge for certain non-multiemployer plans with more than 100 participants,
if applicable (see instructions) 9f
g Total charges. Add lines 9a through 9f 9g
Credits to funding standard account:
h Prior year credit balance, if any 9h
i Employer contributions. Total from column (b) of line 3a 9i
Outstanding Balance
j Amortization credits as of valuation date © ($ ) 9j
k Interest as applicable to end of plan year on lines 9h, 9i, and 9j 9k
l Full funding limitation (FFL) and credits
(1) ERISA FFL (accrued liability FFL) l(1)
(2) “OBRA ’87” FFL (150% current liability FFL) l(2)
(3) “RPA ’94” override (90% current liability FFL) l(3)
(4) FFL credit before reflecting “OBRA ’87” FFL l(4)
(5) Additional credit due to “OBRA ’87” FFL l(5)
m (1) Waived funding deficiency m(1)
(2) Other credits m(2)
n Total credits. Add lines 9h through 9k, 9l(4), 9l(5), 9m(1)and 9m(2) 9n
o Credit balance: If line 9n is greater than line 9g, enter the difference 9o
p Funding deficiency: If line 9g is greater than line 9n, enter the difference 9p
q Current year’s accumulated reconciliation account:
(1) Due to additional funding charges as of the beginning of the plan year q(1)
(2) Due to additional interest charges as of the beginning of the plan year q(2)
(3) Due to waived funding deficiencies:
(a) Reconciliation outstanding balance as of valuation date q(3)(a)
(b) Reconciliation amount. Line 9c(2) balance minus line 9q(3)(a) q(3)(b)
(4) Total as of valuation date © q(4)
10 Contribution necessary to avoid an accumulated funding deficiency. Enter the amount in line 9p
or the amount required under the alternative funding standard account if applicable 10
11 Has a change been made in the actuarial assumptions for the current plan year? If “Yes,” see instructions. Yes No
Note: Changes in actuarial assumptions made for prior plan years for large underfunded plans (other than multiemployer plans)
may be subject to approval. See instructions for a description of changes that are subject to approval.
Schedule B (Form 5500) 1995 Page 4
Part II Additional Information for Certain Plans Other Than Multiemployer Plans
Please refer to Who Must File on page 1 of the instructions to determine if you must complete Part II.
12 Additional required funding charge (see instructions):
a Enter “Gateway %.” Divide line 1b(2) by line 1d(2)(c) and multiply by 100.
If line 12a is at least 90%, go to line 12u and enter -0-.
If line 12a is less than 80%, go to line 12b.
If line 12a is at least 80% (but less than 90%), see instructions and, if applicable, enter the
appropriate plan years and condition codes and go to line 12u and enter -0-. Otherwise, go to
line 12b 12a . %

Plan Year Condition Code

199

199

b “RPA ’94” current liability. Enter line 1d(2)(a) 12b


c Adjusted value of assets (see instructions) 12c
d Funded current liability percentage. Divide line 12c by 12b and multiply by 100 12d . %
e Unfunded current liability. Subtract line 12c from line 12b 12e
f Liability attributable to any unpredictable contingent event benefit 12f
g (1) Outstanding balance of unfunded old liability g(1)
(2) Additional unfunded old liability (see instructions). If the employer
elected the Optional rule, subtract the sum of lines 12f and 12g(1)
from line 12e. Enter -0- if negative. Otherwise, complete line 15
and enter line 15f g(2)
(3) Add lines 12g(1) and 12g(2) g(3)
h Unfunded new liability. Subtract the total of lines 12f and 12g(3) from line 12e. Enter -0- if negative 12h
i Unfunded new liability amount ( . % of line 12h) 12i
j Unfunded old liability amount 12j
k Deficit reduction contribution. Add lines 12i, 12j, and 1d(2)(b) 12k
l Net charges in funding standard account used to offset the deficit reduction contribution. Enter
a negative number if less than zero 12l
m Unpredictable contingent event amount:
(1) Benefits paid during year attributable to unpredictable contingent event m(1)
(2) Unfunded current liability percentage. Subtract the percentage
on line 12d from 100% m(2) . %
(3) Transition percentage m(3) 4 0 . 0 0 %
(4) Enter the product of lines 12m(1), 12m(2), and 12m(3) m(4)
(5) Amortization of all unpredictable contingent event liabilities m(5)
(6) “RPA ’94” additional amount (see instructions) m(6)
(7) Enter the greatest of line 12m(4), 12m(5), or 12m(6) m(7)
Preliminary Calculation
n Preliminary additional funding charge: Enter the excess of line 12k over line 12l (if any), plus line
12m(7), adjusted to end of year with interest 12n
o Contributions needed to increase current liability percentage to 100% (see instructions) 12o
p Enter the lesser of line 12n or 12o. Also, enter the result on line 12t if the employer elected
neither the Optional rule under Code section 412(l)(3)(E) nor the Transition rule under Code section
412(l)(11) 12p
Final Calculation (complete line 12q, 12r, or 12s, as applicable, and lines 12t and 12u)
q If the employer elected to use the Transition rule, but did not elect to use the Optional rule,
complete line 14 and enter the lesser of line 12p or 14f here and on line 12t 12q
r If the employer elected to use the Optional rule, but did not elect to use the Transition rule,
complete line 13 and enter the greater of line 12p or 13q here and on line 12t 12r
s If the employer elected to use both the Optional rule and the Transition rule, enter the lesser of
(1) the greater of line 12p or 13q, or (2) line 14f. Also, enter on line 12t 12s
t Additional funding charge prior to adjustment 12t
u Adjusted additional funding charge. ( . 0 % of line 12t) 12u
Schedule B (Form 5500) 1995 Page 5
13 Additional funding charge under prior law, for use with Optional and/or Transition rules:
a “OBRA ’87” current liability. Enter line 1d(3)(a) 13a
b Adjusted value of assets (see instructions) 13b
c Funded current liability percentage. Divide line 13b by line 13a and multiply by 100 13c . %
d Unfunded current liability. Subtract line 13b from line 13a 13d
e Outstanding balance of unfunded old liability 13e
f Liability attributable to any unpredictable contingent event benefit 13f
g Unfunded new liability. Subtract the total of lines 13e and 13f from line 13d 13g
h Unfunded new liability amount ( . % of line 13g) 13h
i Unfunded old liability amount 13i
j Deficit reduction contribution. Add lines 13h and 13i 13j
k Net amortization charge for certain bases 13k
l Unpredictable contingent event amount:
(1) Benefits paid during year attributable to unpredictable contingent event l(1)
(2) Unfunded current liability percentage. Subtract the percentage
on line 13c from 100% l(2) . %
(3) Transition percentage l(3) 4 0 . 0 0 %
(4) Enter the product of lines 13l(1), 13l(2) and 13l(3) l(4)
(5) Amortization of all unpredictable contingent event liabilities l(5)
(6) Enter the greater of line 13l(4) or line 13l(5) l(6)
m Additional funding charge (excess of line 13j over line 13k (if any), plus line 13l(6) 13m
n Assets needed to increase current liability percentage to 100% (line 13d) 13n
o Smaller of line 13m or line 13n 13o
p Interest adjustment 13p
q Additional funding charge. Add lines 13o and 13p 13q
14 Transition rule:
a Initial funded current liability percentage. Enter the percentage from line 12d here 14a . %
b Applicable percentage for transition rule (see instructions) 14b 0 . %
c Target percentage. Add lines 14a and 14b (see instructions) 14c . %
d Contributions needed to increase the funded current liability percentage to the target percentage
(see instructions) 14d
e Enter the amount from line 13q here (Additional funding charge under prior law) 14e
f Additional funding charge under transition rule of Code section 412(l)(11)(E): Enter the greater
of line 14d or 14e 14f
15 Additional unfunded old liability without optional rule:
a Interest rate used to determine current liability for the first plan year beginning after 12/31/92 15a . %
b Weighted average interest rate under Code section 412(b)(5)(B)(ii)(I) for the first plan year
beginning after 12/31/94 15b . %
c Weighted average interest rate under Code section 412(b)(5)(B)(ii)(I) for the first plan year
beginning after 12/31/92 15c . %
d “Prior interest rate.” Multiply line 15a by line 15b and divide the result by line 15c 15d . %
e Current liability as of valuation date, valued using the prior interest rate on line 15d, and mortality
assumptions used to determine current liability for the first plan year beginning after 12/31/92;
all other assumptions are the same as those used for line 12b 15e
f Additional unfunded old liability. Subtract line 15e from line 12b. Enter -0- if negative 15f
Printed on recycled paper

You might also like